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Have you ever been evaluated for orthodontic treatment?
I have gone through treatment before
Are you happy with the way your smile looks?
My smile affects my confidence
What are the MAIN orthodontic concerns you would like to fix?
Address Line 1
Address Line 2
District of Columbia
Social Security Number
This is required to determine insurance eligibility. Please call our office if you prefer not to provide online.
What is the best method to contact you?
When is the best time to reach you?
Please provide a specific time if needed
How did you hear about us?
Google / Online
Family / Friend
Name of Person who Referred you
Name of Spouse
If NO occupation, Please leave BLANK
Work Phone Number
DENTAL Insurance Information
Please provide Dental Insurance under which you are covered. This may be Spouse's Dental Insurance.
Do you have Dental Insurance Coverage?
Dental Insurance Card
Click or drag files to this area to upload.
You can upload up to 2 files.
Please take a photo of the FRONT and BACK of your insurance card. You don't have to fill out insurance info if you upload photos!
Name of Dental Insurance
I.e. Delta, Aetna, United Concordia... If NO insurance, please leave BLANK
Do they cover orthodontic treatment?
I'm Not Sure
Name of Insured
Your name, if covered under your own insurance. Spouse or other's name, if covered under their insurance.
Insured's Relation to Patient
Insured Date of Birth
Please provide month/day/year. If same as your DOB, please respond: Same
Employer under which policy is offered. If same as your employer, respond: Same
Dental Insurance GROUP #
Dental Insurance ID #
Dental Insurance Phone #
Who is your Dentist (or last Dentist)?
If you do not have a current dentist, please respond: None
When was your last dental visit?
6 months or less
6 months to 1 year
Over 1 year
How would you describe your dental health?
Have you ever had trauma to your Teeth or Jaws?
Please describe the injury to your teeth or jaws, including the date it happened:
Have you Ever had a Serious/Difficult problem associated with anyPrevious Dental Work?
Please describe previous dental problems
Have you Now, or Ever experienced Pain or Discomfort in your Jaw Joint (TMJ?)
Please describe pain in TMJ?
Do you have any speech problems?
Do you generally breathe through your mouth?
This section will determine if there are any medical concerns that may interfere with orthodontic treatment
Have you EVER taken medication for Osteoporosis?
This includes Fosamax, or medications known as Bisphosphonates
Please provide Name of Medication and How it is, or was Taken
Taken by mouth, or injected by doctor
Any Artificial Bones/Joints/Heart Valves?
Please describe artificial bones/joints/heart valves, and dates of placement
Have you EVER been under the care of a physician for a medical condition or chronic illness?
Please describe the medical condition requiring a physician's care:
I.e. High Blood Pressure, or Cancer treatment, or Lymes Disease, etc...
Are you taking prescribed medications?
Please List your prescribed medications:
I.e. Atorvastatin (Lipitor) for Cholesterol.... or Amlodipine for BP (blood pressure), etc...
Have you ever been hospitalized for a life threatening injury / disease?
Please describe reason for hospitalization:
Have you ever been diagnosed with:
Herpes / Fever Blisters
HIV / AIDS
Rheumatic / Scarlet Fever
Abnormal Bleeding / Hemophelia
Congenital Heart Defect
Epilepsy / Seizures
High Blood Pressure
Low Blood Pressure
Mitral Valve Prolapse
Sickle Cell Disease / Trait
Are there any Additional Concerns you have that were not addressed above?